Marion nursing home cited over allegations of death, abuse and understaffing


This photo from 2019 shows the Willow Gardens care center in Marion. The facility was sold in May 2020 and its name changed to Silver Oak Nursing and Rehabilitation Center. State inspectors cited the center for more than two dozen health care violations. (Google StreetView)

A nursing home in Marion has been cited for more than two dozen health care violations and is accused of being so short-staffed that residents have not received food or medicine as scheduled.

A resident of Marion’s Silver Oak Nursing and Rehabilitation Center died at home after a fall on Thanksgiving.

The alleged physical abuse of another resident was not reported to the state as required by law, and some temporary employees reportedly arrived at work and immediately left after seeing how understaffed the facility was. .

The facility was cited for 25 separate violations of federal regulations. He now faces a $12,500 fine, which could be reduced to $8,125 if the owners agree to waive an appeal.

Inspectors allege the home failed to meet minimum standards relating to resident abuse, professional standards of care, cardiopulmonary resuscitation, pressure ulcers, accident risk, incontinence care, dialysis, frequency of doctor visits, maintaining sufficient numbers of nursing staff, dietary issues, frequency of meals and snacks, food storage and preparation, and infection prevention.

After filing several complaints about the quality of home care, inspectors visited the facility in December, resulting in 25 separate findings of insufficient care and the $12,500 fine.

At that time, the home was also cited for failing to provide a safe transfer for a resident who suffered a broken hip, for failing to report a serious injury to state inspectors, and for failing to document possible causes and interventions for a resident who sustains multiple fractures in a fall.

A resident who fell was found on the ground screaming in pain and shouting, “Take me to the hospital, I don’t feel well, I need a doctor, I need a doctor.” The resident was taken to hospital and died shortly thereafter.

Personnel issues

Inspectors also found that the home did not employ enough staff with the necessary skills to meet the food and nutrition needs of residents.

They reported that only three employees – the activities director, a central supply staff employee and a dietary aide – worked in the kitchen during lunch to serve 52 residents.

The housekeeping supervisor of the house and the activity director told the inspectors that they expected to cook in the kitchen that evening.

There was no dietitian on staff and the head of the maintenance department reported that company executives had asked him to help in the kitchen, suggesting that he puree food for residents who could not eat solid foods.

A nurse told inspectors she was forced to withhold residents’ insulin due to meals being served so late. Nine residents were left with low blood sugar while waiting for their meals.

The home was cited for being understaffed, with a nursing assistant telling inspectors she and another worker had to care for 30 residents during an eight-hour shift. The workload was too heavy, she said, and residents weren’t getting to the bathroom, dining room or going to bed on time.

A registered nurse alleged that the company sometimes refused to let the home bring in temporary workers from an agency, prompting the home’s own workers to quit.

Another nurse said medical treatment for residents was not being done and she had found medical prescriptions for residents who had been “sitting there for a week” and not being treated.

Another employee said that on some occasions the house has brought in temporary workers from placement agencies, only for the temps to enter the building, find they were the only assistant working with 52 residents, and walk out.

Alleged abuse

The home’s director of rehabilitation told inspectors that in November a tearful resident reported to him that a nurse’s aide had pushed her a wheelchair because she needed to use the bathroom, leg injury. The director of rehabilitation immediately reported the allegation to the administrator of the home.

The administrator reportedly confirmed the potential abuse, but the company owner’s vice president of clinical operations told him to refrain from reporting the matter to the Iowa Department of Inspections and Appeals.

Janet Bryant, director of clinical operations at the facility’s owner, Ivy Healthcare Group, denied ever giving the directive. “I would never, ever, ever tell anyone not to report an allegation of abuse,” she told the Iowa Capital Dispatch.

Silver Oak has also been accused of failing to ensure residents who rely on Medicaid are seen by a doctor every 30 to 60 days.

A resident with paralysis, Parkinson’s disease and schizophrenia had not seen a doctor for seven months. Another resident, who suffered from heart failure, end-stage kidney disease and diabetes, had not seen a doctor for six months.

Florida owner

Until last year when the house was sold, it was known as Willow Gardens Care Center and had been operating for three years without fines or citations. Last May, the facility was purchased by Surfside, Florida-based Ivy Healthcare Group.

Ivy Healthcare President and CEO Ryan Coane, when asked about non-diet workers in the kitchen, told the Iowa Capital Dispatch, “There may have been a situation like this, you know, where there was some sort of delay, where other staff had to go to the kitchen and help out. If I was in the facility myself, I would go into the kitchen and help with what is needed.

Coane admitted that he had never been to Silver Oak. He said if the facility had to bring in agency staff to meet the needs of residents, that’s not something he would ever turn down.

In November, he told Skilled Nursing News that his company had nine facilities and hoped to grow based on the economic opportunities that exist by avoiding the use of temporary staff.

“Some (nursing facilities) have still maintained very good margins because we operate in small towns and there is not as much competition,” he said.

He said his company acquired a facility in May 2021 – the same month the company bought Marion’s home – after seeing the benefits the deal would have if it was able to reduce reliance on contractors. interim temporary workers who increase personnel costs.

Coane also told Skilled Nursing News that his company paid “astronomical rates” for agency-employed nurses, with salaries reaching $100 per hour for registered nurses and $50 per hour for registered nurses. certified nursing aides.

Bryant, director of clinical operations for the company, said Thursday that Ivy Healthcare Group has yet to give the state a written plan to address the issues cited by inspectors last month.

She asked why the media would even have access to the inspectors’ findings at this stage. “It’s not a public record,” she said.

In addition to Silver Oak, Ivy Healthcare Group also operates The Ivy in Davenport. According to state records, the Davenport home was fined $288,330 in 2021 by the federal Centers for Medicare and Medicaid Services, later reduced to $192,664.

This article first appeared in the Iowa Capital Dispatch.

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